Crepitus

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I had this one pt last week and this has been eating at me. The pt had a right sided chest tube. Suction was d/c'd that day and it was to gravity drainage. The tube was sutured in place. He slept throughout the night but at 5 am he had a 3rd dose of solu medrol which was started the day before. Our techs do hourly rounds on the pts and I will pop my head in to make sure that everyone is sleeping soundly or if they're awake see if there's a problem. He called about 6:15 saying that he was having some swelling of his face. I go in and sure enough his face is markedly swollen. He was having no problems breathing, no problems swallowing and no pain, but just some edema of the face and neck. I immediately call his attending (but it was his partner who was on-call)who said it was probably edema related to the solu-medrol. I explained what a change it was from 5 to 6:15. He said he'd see him first when he came in. I relayed all of this information back to the pt and reassessed the fact he was having no breathing/swallowing problems or pain but told him to call me if he was having any further changes or problems.

At shortly after 7 as I'm giving report to the next shift, the doctor comes out to the nurses station and says the pt has crepitus and he was going to call the pulmonary sugeon who put the chest tube in. He also calls his colleague who is the true attending. Myself and the oncoming nurse go in because frankly neither of us has ever seen crepitus and wanted to have a feel as did many on the floor. One seasoned nurse said that in 15 years she's never seen crepitus in a pt. I finish giving report going in to the pt to again reassess for any discomfort or difficulties in airway or swallowing noting that his right eye was beginning to swell which I relayed back to the oncoming nurse and document the whole series of events that had occurred.

I go in that night and look at the pt board and see he's not in my section, so I ask the CC why. She said that the family was very upset and felt I didn't do enough to help him out or didn't check on him enough through the night. He was checked on by someone hourly! I also found out that when the dr who visited him called the attending he was asked if the chest tube was connected to suction and he said yes. When the attending came in around 1pm and found it wasn't (because the thoracic surgeon d/c'd the suction the day before) he went through the roof and the pt suffered with the edmea of the crepitus from 5am until at least 1 when the suction was applied and the edema started to go down. The chest tube was repositioned and the surgeon went ballistic that he wasn't called first. However later that day (he was another nurse's pt) he had a relapse of the crepitus and quickly fixed. I had the weekend off and thought he was discharged and found he's on another floor. Not upgraded, not downgraded but just another med/surg floor. All of a sudden we all had to attend an in-service on chest tubes and crepitus and they referenced that pt (not knowing it was me who had him that first night).

A friend of mine told me to make sure my insurance is paid up in case he decides to sue. Now I'm all paranoid that I did something wrong. I'd never seen crepitus. Many of the other more seasoned nurses have never seen crepitus. Even the educator who's been a nurse for 30 years says shes only seen it twice. My first thought was allergic reaction (but to solu-medrol?) and wasn't really buying that it was swelling from the med, but I would not have thought crepitus. What do y'all think?

I always associated crepitus as the sound/feeling of bone ends moving against each other from fracture. Crepitus was apparent on palp to the scapular area as the bone was fractured.

I wonder if what you are referencing is subcutaneous air in the tissues. I usually reference this as a "rice krispie" type crackling on palp.

Just wondering???

I would imagine that IF subQ air was the case and the respiratory status remained free of genuine compromise, it is well - what it is. A limited complication.

I have seen probably a dozen or so cases of subQ emphysema - usually associated with massive injury to the airway or associated structures. It is not uncommon after new trach placement. The few cases that I recall of limited subQ air were NOT associated with any permanent damages. Specific treatment usually focuses on resolution of the underlying cause - I've also seen some freaky attempts to relieve it (by needle decompression, no less) - but it usually resolves over time.

I think you observed/assessed/reported your patient in an a timely, professional manner. Don't let the family get to you - I would just mark it up to a personal decision from the family.

Don't sweat this too much. Report as required by your facility. Discus with your clinical manager/risk manager. Make sure your documentation is top rate and now RELAX.

Just keep on - and I'm willing to bet that you will never forget this, keep in mind that there was no tragic outcome - so it is a lesson learned. That is all.

Focus on being the wonderful nurse that you are - and now you are a wee bit wiser too! Sounds like you did a good job for the patient to me.

I guess that yes, the new PC term is subQ emphysemia, but i learned it as crepitus and you're right it could also mean the term with bones grinding against each other. One of those dual termed words.

I guess I'm just paranoid because I'm still in my first year of nursing and while I have been trained really well, I just don't want inexperience to cause me to make a mistake. The clinical coordinator told me not to worry about it that it was mostly a series of misQ's between the doctors. The guy's swelling is gone now, his chest tube has since been removed, but still. Thanks for the reassurance. I just wanted to pass it by some experienced 'worldly' nurses. :-)

Crepitus is not something easily recognized if you've never actually seen it before, so I'm not surprised you didn't realize what it was. It's not your fault the on-call doc screwed up his report to the actual attending, or that the surgeon wasn't called sooner. Definitely inservice is needed but I don't think you did anything horribly wrong.

PS, your notes should support your actions...do aides record hourly rounding on charts? Fact that doc saw him in AM helps share responsibility for pts care.

Lesson learned, if it doesn't seem right, go up the chain of physician command. Inservice will help with care of Chest tubes. Lessons learned from this "nursing adventure" will stay with you forever. Guess who will be the chest tube guru now YOU!

My understanding of crepitus in this pt is that he had crackles in the lungs due to all the fluid accumulation. Did anyone listen to his lungs? I don't believe you are at fault. You did not D'C the suction. You simply followed the orders.

I'm with Karen. Have seen crepitus as described several times with chest tubes. Think of it as air trapped under the skin- you have air leaking out, so if it's not self-contained to a small area like in the OP's pt, that's why you put the pt back to suction ASAP. Always palpate edemaous sites, so you can feel for crepitus. You can have crepitus with fractures as well, but it's usually around bursa, skull fx's (think sinuses), or with rib fx's.

My understanding of crepitus in this pt is that he had crackles in the lungs due to all the fluid accumulation. Did anyone listen to his lungs? I don't believe you are at fault. You did not D'C the suction. You simply followed the orders.

crepitus=subq emphesyma is air under the skin, which has escaped from the lung (air Leak). Listening to his lungs is always good but wouldn't have changed the situation, usually the lungs sound aren't effected.

The crepitus itself doesn't harm the patient it is just very annoying if it is in large area. I have seen the entire face, neck, and down to the affected chest. It means there is an air leak and should be to suction.

I would hope that the charge nurse took time to explain to the family that you did what was appropiate, and truly most likely no harm was done, esp. if he wasn't not having any breathing difficulties.
I have seen this often, and it is scary to families, because it doesn't look normal. I have worked with chest tubes for over 15 years, post thoracotomy as well as ct placed for pneumothorax. So stop beating yourself up over, you did what you should have done.

His lung sounds (vitals are done q 12 hrs) were slighly diminished. The suction was d/c'd that day because they were planning on removing the chest tube the next day (the day the crepitus showed up) and they just wanted the fluid to gravity drainage and even then there was only 10ml in a 24 hour period. I didn't think to palpate the edema around his face and even after we were told it was crepitus the only place you felt that 'rice krispy' feel was only around his clavicles and shoulders but no where else in his neck or face.

The in-service has been very informative and gave me some great interventions to possible complications and things to check for. Policies and prodcedures are in the process of being re-written to accomodate such problems.

Crepitus isn't encountered as much today, as I have in the past. I once was driving home from the store on a highway, and saw this car upside down in the middle of a yard. Pulled over and found the driver thrown out through the window, several yards from the car,(it flipped 3 times) and he was laying unconscious, with his neck at a weird angle. First , of course, ABCs, and I made sure he was breathing, held his neck so it would not move should he awaken. No alcohol on breath, but felt the crepitus as I was basically feeling for fractures around clavicle, neck, etc. Called 911, had to wait forever for ambulance, even after they arrived, it took forever. Reported the crepitus, and LOC since I arrived, put on collar, and the paramedic, told me, You wouldn't know if it were crepitus, and he doesn't have it. WRONG< he did, lung down, needed resusciation n ambulance,and spent weeks n ICU, Had a brain injury. I don;t remember when I learned to assess it , I had lots of certifications, but think maybe it was the trauma certification, as the instructor for that particular time, let motorcycle injuries dominate, and we did lots of detailed assessments, plus learned to take of the helmet of a rider,that flipped,dented, etc.
You took the steps outlined in the protocol for your unit. The physcian should have noted the signs. BUT they miss too. Perhaps the attending should have addressed his frustrations with the ON call dr.